Saudi Journal of Kidney Diseases and Transplantation

: 2020  |  Volume : 31  |  Issue : 5  |  Page : 1062--1068

Five-Year Mortality Analysis in Hemodialysis Patients in a Single-Center in Dubai

Maseer Ahmed, Fakhriya Alalawi, Hind AlNour, Kashif Gulzar, Amna Alhadari 
 Department of Nephrology, Dubai Hospital, Dubai Health Authority, Dubai, United Arab Emirates

Correspondence Address:
Fakhriya Alalawi
Department of Nephrology, Dubai Hospital, Dubai Health Authority, Dubai
United Arab Emirates


The purpose of this study is to determine the mortality among patients on hemodialysis (HD). This observational cohort study was conducted at Dubai Hospital during the period between January 2012 and December 2016. All adults’ patients with end-stage renal disease (ESRD) on HD irrespective of their age, gender, and duration of dialysis were enrolled. Mortality among these patients along with certain information like age at the time of death, gender, cause of ESRD, comorbidities, and serology report, were collected. Out of a total of 411 patients, 112 (27.3%) patients died during the study period, 56% were male and their median age at the time of initiation of dialysis and at the time of death was 59.38 ± 13.5 and 63.8 ± 13.6, respectively. Thirteen patients suffered early mortality; i.e., died within 365 days of initiation of dialysis. Diabetes mellitus (DM) was the most common cause of ESRD (73%) among the deceased populations, whereas hypertension was the most prevalent comorbidity in our study group. Anemia (46%), hypoalbuminemia (54%), and hypoparathyroidism (72%), whereas high ferritin (63%) and abnormal phosphorus (61.6%) were predominant biochemical parameters in the deceased patients. The leading cause of death was cardiovascular in 48 patients (42.85%) followed by infection/sepsis (21 patients, 18.75%), unknown causes/sudden death (including sudden death at home) in 18 patients (16.07%) and cerebrovascular events in seven patients (6.2%). Other causes include gastrointestinal hemorrhage, liver disease, and pulmonary embolism. In general, older age group, DM, prolonged duration on dialysis and cardiac diseases were the common causes of mortality in our study population. We found that the conventional risk factors such as old age, diabetes, cardiovascular disease, duration on dialysis, dialysis adequacy, low hemoglobin and low albumin, abnormal phosphorus, and high ferritin are comparatively prevalent in our study patients. Monitoring and timely intervention of these risk factors can help in reducing mortality in future.

How to cite this article:
Ahmed M, Alalawi F, AlNour H, Gulzar K, Alhadari A. Five-Year Mortality Analysis in Hemodialysis Patients in a Single-Center in Dubai.Saudi J Kidney Dis Transpl 2020;31:1062-1068

How to cite this URL:
Ahmed M, Alalawi F, AlNour H, Gulzar K, Alhadari A. Five-Year Mortality Analysis in Hemodialysis Patients in a Single-Center in Dubai. Saudi J Kidney Dis Transpl [serial online] 2020 [cited 2021 Sep 19 ];31:1062-1068
Available from:

Full Text


In spite of the advancement and general improvement in the treatment of end-stage renal disease (ESRD), its incidence is increasing worldwide.[1],[2],[3] Globally, more than two million peoples are on dialysis or underwent renal transplants to stay alive.[4] Moreover, it was estimated that one in five men and one in four women aged in between 65 and 74 are suffering from chronic kidney disease (CKD).[5] According to the estimates given by the World Health Organization, in 2005, out of average 58 million mortality worldwide, 35 million deaths were caused by CKD,[6] also according to Center for Disease Control, CKD is ranked 8th most common cause of mortality in the USA in 2017 (13 deaths per 100,000 population).[7] A study on the basis of data reported by 18 countries revealed that approximately 350.2 per million patients are on dialysis.[8] Furthermore, mortality is an important way to determine the outcome in dialysis patients. This study was conducted with the aim to determine the mortality among patients on hemodialysis (HD). Cardiovascular and cere-brovascular diseases are the two most important causes of morbidity and mortality in ESRD patients[3],[4] especially in diabetics[5],[6] and those with lupus erythematosus.[8] Cardiovascular diseases (CVDs) are more common in ESRD patients as compared to the general population.[9],[10],[11],[12] According to the United States Renal Data System (USRDS) 2015, congestive heart failure was present in 40%, coronary heart disease in 42%, and myocardial infarction in 12% of the ESRD patients. CVDs are the leading cause of death in ESRD patients; cardiac arrest accounts for 40% of the total deaths.[13] Among diabetics, CVD-related mortality is higher as compared to nondiabetics.[14],[15] The survival rate is an important outcome measure in dialysis patients. According to the National Kidney Foundation, life expectancy for ESRD patients varies differently, dependent on comorbidities, quality, and compliance to dialysis. Average life expectancy is 5–10 years, however many patients survive quite well on dialysis for 20–30 years.[16],[17] As per USRDS 2015 data, the mortality rate is 40.6 per 100 patients/year in the age-group 65–74 years and increases to 68.9 per 100 patients/ year in patient's ages 75 years and older.[13] The mortality rate depends on age, sex, race, cause of ESRD, the modality of treatment and its complication besides unknown reasons. Elderly, male white American patients, and comorbid illness like diabetes, hypertension, and infections are considered the main factors behind high mortality in dialysis patients.[18]

 Materials and Methods

Medical records of 411 ESRD patients who were on dialysis between January 2012 and December 2016 were reviewed at Dubai Nephrology Department, Dubai Hospital, Dubai. Demographic data (name, age, sex), the etiology of ESRD and duration of renal replacement therapy (RRT) were recorded. Laboratory profile, comorbidities, complications during dialysis, and cause of death were also studied. Comorbid conditions such as diabetes mellitus (DM), CVDs, virology report, neoplasms, vascular diseases, and hypertension were considered. Laboratory parameters like hemoglobin level, calcium level, serum phosphate level, albumin level, parathyroid hormone, urea, creatinine, uric acid estimation, liver function tests, iron saturation, and serum ferritin level were also explored, in addition to the dialysis adequacy and nutritional status. The statistical analyses were performed using IBM SPSS Statistics for Windows version 26.0 (IBM Corp., Armonk, NY, IL, USA). Results were systematically tabulated and statistically analysed. Descriptive statistics were calculated for quantitative variables (mean, SD, and median in the case of skewed distribution) and for qualitative variables, absolute and percentage frequencies. Mann–Whitney U-test was applied to see the difference of these variables with mortality. Chi-square test was applied to see the association of mortality with confounding variables, such as gender, ESRD causes, comorbidities, previous renal transplant status, and serology report. P <0.05 was taken as significant.


One hundred and twelve (27.2%) fatalities occurred in 411 dialysis patients during the conduct of this retrospective study in the span of five years with an annual death rate/year of 13%–20% (average 16.2%). Mean age among the expired patients at the start of HD was 59.38 ± 13.55, with 31% of patients were 55 years or less, whereas 69% were >60 years of age at the time of death, there were more males as compared to females, i.e., 56% and 44% respectively [Table 1]. Thirteen patients (11.6%) died during the 1st year of dialysis, while 53.7% were dialyzed for >3 years [Table 1]. Eighty-six percent of patients were not suffering from a viral illness (HBV, HCV, and HIV), whereas the rest were suffering from one or more viral infections [Table 1]. Regarding the cause of kidney disease, diabetes and hypertension were the two most common among deceased patients, affecting 89% [73% (82) and 16% (18) respectively] patients, also obstructive uropathy, chronic glomerulonephritis and other miscellaneous disorders affect 11% of patients [Table 1]. Frequency of comorbidities showed that hypertension was found higher (n = 98, 88%) followed by DM (n = 89, 79%), cardiac disease (n = 59, 53%), vascular disease (n = 24, 21%), [Table 2]. Low hemoglobin (46%, n = 50), abnormal phosphorus, low parathyroid hormone (72%, n = 75), low albumin (54%, n = 58), and high ferritin (63%, n = 66) are pre-dominant laboratory parameters in deceased population [Table 3], whereas 35.7% only of deceased patients had received adequate dialysis (URR ≥65%). Cardiac events and infection/sepsis are two most common cause of death in our study population, comprising of 43 and 18.7% [Table 4]. Among sepsis patients, frequent organisms were Enterococcus, Staphylococcus aureus, and Staphylococcus epidermidis.{Table 1}{Table 2}{Table 3}{Table 4}


In maintenance HD patients, mortality rates are higher than the general population. Here death pattern was analyzed in 112 (27.2%) patients from a total of 411 patients using retrospective data in the nephrology department of Dubai hospital. Our results showed that mortality rates are highest among patients aged more than 60 years (69.7%), Al-Wakeel et al[10] observed somewhat similar numbers whereas USRDS[13] and Robinson et al[19] reported 49% and 51.1%, respectively. Diabetes was the most common cause of ESRD in our population, 73% of the deceased was suffering from it, compared to 38.6% reported by Robinson et al[19] and 28.6% of USRDS[13] patients, the difference of sample size probably explains the difference in figures. High prevalence of DM may explain the highest mortality in dialysis patients since on the one hand it affects vascular access maturity and on the other hand, it deteriorates arterial stiffness and vascular calcification, hence diabetes and ESRD synergistically increase cardiovascular mortality.[20],[21] Hypertension and diabetes were the most common comorbidities among our population, followed by cardiac, vascular, and liver disease. Malignancy was not reported in any of our studied patients. Many factors influence the survival in dialysis patients; CVD is associated with the worst survival in dialysis patients. Studies have reported up to 10 to 20 times higher CVD associated mortality in dialysis as compared to the general population.[22] Chang et al observed 3.3 times higher mortality risk in dialysis patients suffering from DM and CVD than dialysis patients without DM or CVD.[23] Leading cause of death in our study group was cardiac (48, 42.8%), and 43% of total patients were suffering from diabetes and CVD both. Similarly, Al Wakeel et al[10] and Tong et al[24] found CVD as the most common reason for fatality (41.1% and 44%, respectively). Foley et al reported left ventricular hypertrophy in 73.9% and systolic dysfunction in 14.8% of patients.[25] High mortality after initiation of dialysis is a recognized fact now, The European Renal Association – European Dialysis and Transplant Association registry (European renal association) suggests 86% survival probability in the 1st year.[26] Low albumin, catheter-related sepsis, dialysis complications, old age are some reasons that might explain this phenomenon. We observed 13 (11.6%) fatalities in the 1st year of dialysis, seven males and six females. Eight were above 60 years of age. Robinson et al observed 25% of patients died in the first 365 days in DOPPS study[19] and Bradbury et al in US HD patients where the mortality risk was elevated during the first 120 days compared with the next 121 to 365 days (27.5 vs. 21.9 deaths/100 person-years; P = 0.002).[27] Noordzil and Jager called this universal phenomenon.[28]

Though our patient sample is small, reflecting a single center data, yet we have an average annual death rate/year of 16.2%, comparable to Europe (15.6%), higher than in Japan (6.6%), but relatively better than in USA (21.7%).[29] The mortality rate is inversely associated with the dose of dialysis; Held et al reported 7 and 11% decrease in mortality rate by increasing 0.1 in Kt/V and 5% in urea reduction ratio.[30] In our study group, 64.3% of deceased patients received inadequate dialysis mostly because of access-related issues and noncompliance to follow dialysis prescription, particularly the elderly. Certain hematological and biochemical parameters may also predispose the dialysis population to high mortality. Anemia is one of the important factors to determine mortality in dialysis patients. Low hemoglobin and hematocrit are associated with higher infection, higher hospitalization rate, reduced quality of life and increases the burden on the heart.[31] Approximately half of our deceased patients (45.4%) at their time of death had a hemoglobin less than 10 g/dL, correspondingly Koilin et al had reported in Taiwan population 62% of fatalities in dialysis patients with hemoglobin less than 10 g/dL.[32] Importance of phosphorus as a prognostic factor of morbidity and mortality in dialysis patients is recognized universally, one plausible explanation could be the involvement of phosphorus in vascular calcification[33] and left ventricular hypertrophy, which contributes to cardiovascular disease and death.[34] Eddington et al[35] observed that high phosphorus can increase all-cause mortality in dialysis patients; we found 37% of our study population had high phosphorus. Albumin and Ferritin levels are of prognostic significance in dialysis patients, Inflammation causes rise in ferritin and decrease in albumin, which in turn increase all-cause of mortality in dialysis patients[36] whereas Park et al proposed that association of high ferritin at the time of initiation of dialysis is independent risk factor of mortality regardless of systemic inflammation and nutrition.[37] We observed high ferritin (more than 500 ng/mL) in 63% and low albumin (<3.5 g/dL) in 55.3% of our deceased dialysis population, de Mustert et al suggest that 1 g/dL decrease in albumin will increase mortality risk of 47% in HD patients, that was partly explained by inflammation, also he implies that low albumin in his study population was not consequence of malnutrition as measured with subjective global assessment and normalized protein nitrogen appearance.[38] We have an average annual death rate/year of 16.2%, our death rate can be still incredibly low, however, since the majority of our population were >60 years of age (70%) and mostly were diabetics, and the two factors on itself are outstanding indicators of high mortality, which had pondered adversely our rate.


Our study explored a single-center experience of mortality in HD patients. We found that the mortality rate in our study group was comparable to other international data, rather we have reduced death rates as compared to many developed countries, and the conventional risk factors either fixed like old age or relative such as diabetes mellitus, CVD, duration on dialysis, dialysis adequacy, low hemoglobin and albumin, high phosphorus and ferritin levels are comparatively prevalent in our study patients. Monitoring and timely intervention of relative risk factors can help in reducing mortality in the future.

Conflict of interest: None for all authors.


1Oliveira MB, Romão JE Jr., Zatz R. End-stage renal disease in Brazil: Epidemiology, prevention, and treatment. Kidney Int Suppl 2005; 68(Suppl 97):S82-6.
2Grassmann A, Gioberge S, Moeller S, Brown G. ESRD patients in 2004: Global overview of patient numbers, treatment modalities and associated trends. Nephrol Dial Transplant 2005;20:2587-93.
3Boddana P, Caskey F, Casula A, Ansell D. UK Renal Registry 11th Annual Report (December 2008): Chapter 14 UK Renal Registry and international comparisons. Nephron Clin Pract 2009;111 Suppl 1:c269-76.
4Couser WG, Remuzzi G, Mendis S, Tonelli M. The contribution of chronic kidney disease to the global burden of major noncommunicable diseases. Kidney Int 2011;80:1258-70.
5World Kidney Day: Chronic Kidney Disease. Available from: http://www.worldkidneyday. org/faqs/chronic-kidney-disease/. [Last accessed on 2020 Apr 19].
6Levey AS, Atkins R, Coresh J, et al. Chronic kidney disease as a global public health problem: Approaches and initiatives - a position statement from Kidney Disease Improving Global Outcomes. Kidney Int 2007;72:247-59.
7Center for Disease Control and Prevention-Mortality Data. Available from: https://www. [Last accessed on 2019 Apr 03].
8Cusumano A, Garcia-Garcia G, Di Gioia C, et al. End-stage renal disease and its treatment in Latin America in the twenty-first century. Ren Fail 2006;28:631-7.
9El Minshawy O. End-stage renal disease in the El-Minia Governorate, upper Egypt: An epidemiological study. Saudi J Kidney Dis Transpl 2011;22:1048-54.
10Al Wakeel JS, Mitwalli AH, Al Mohaya S, et al. Morbidity and mortality in ESRD patients on dialysis. Saudi J Kidney Dis Transpl 2002;13:473-7.
11El Minshawy O, Ghabrah T, El Bassuoni E. End-stage renal disease in Tabuk Area, Saudi Arabia: An epidemiological study. Saudi J Kidney Dis Transpl 2014;25:192-5.
12Reikes ST. Trends in end-stage renal disease. Epidemiology, morbidity, and mortality. Postgrad Med 2000;108:124-6, 129-31, 135-6 passim.
13United States Renal Data System-Annual Data Report 2018. Available from: https://www. [Last accessed on 2019 Apr 03].
14Afifi A, El Setouhy M, El Sharkawy M, et al. Diabetic nephropathy as a cause of end-stage renal disease in Egypt: A six-year study. East Mediterr Health J 2004;10:620-6.
15Rao PS, Schaubel DE, Jia X, Li S, Port FK, Saran R. Survival on dialysis post-kidney transplant failure: Results from the Scientific Registry of Transplant Recipients. Am J Kidney Dis 2007;49:294-300.
16Foster BJ, Mitsnefes MM, Dahhou M, Zhang X, Laskin BL. Changes in excess mortality from end stage renal disease in the United States from 1995 to 2013. Clin J Am Soc Nephrol 2018;13:91-9.
17Alalawi F, Ahmed M, AlNour H, Noralla M, Alhadari A. Epidemiology of end-stage renal disease in Dubai: Single-center data. Saudi J Kidney Dis Transpl 2017;28:1119-25.
18USRDS Annual Data Report: Executive Summary. Available from: https://www.usrds. org/adr.aspx. [Last accessed on 2020 Jun 19].
19Robinson BM, Zhang J, Morgenstern H, et al. Worldwide, mortality risk is high soon after initiation of hemodialysis. Kidney Int 2014; 85:158-65.
20Panday VB, Tong ZP, Ng PLet al. Dialysis modality and 2-year outcomes in patients with ischemic cardiomyopathy and end-stage renal disease. Int J Cardiol 2014;176:1097-9.
21Chang YT, Wu JL, Hsu CC, Wang JD, Sung JM. Diabetes and end-stage renal disease synergistically contribute to increased incidence of cardiovascular events: A nationwide follow-up study during 1998-2009. Diabetes Care 2014;37:277-85.
22Foley RN, Parfrey PS, Sarnak MJ. Clinical epidemiology of cardiovascular disease in chronic renal disease. Am J Kidney Dis 1998;32:S112-9.
23Chung SH, Han DC, Noh H, et al. Risk factors for mortality in diabetic peritoneal dialysis patients. Nephrol Dial Transplant 2010;25: 3742-8.
24Tong J, Liu M, Li H, et al. Mortality and Associated Risk Factors in Dialysis Patients with Cardiovascular Disease. Kidney Blood Press Res 2016;41:479-87.
25Foley RN, Parfrey PS, Harnett JD, et al. Clinical and echocardiographic disease in patients starting end-stage renal disease therapy. Kidney Int 1995;47:186-92.
26Kramer A, Pippias M, Noordzij M, et al. The European Renal Association - European Dialysis and Transplant Association (ERA-EDTA) Registry Annual Report 2016: A summary. Clin Kidney J 2019;12:702-20.
27Bradbury BD, Fissell RB, Albert JM, et al. Predictors of early mortality among incident US hemodialysis patients in the Dialysis Outcomes and Practice Patterns Study (DOPPS). Clin J Am Soc Nephrol 2007;2:89-99.
28Noordzil M, Jager KJ. Increased mortality early after dialysis initiation: A universal phenomenon. Kidney Int 2013;85:12-4.
29Goodkin DA, Bragg-Gresham JL, Koenig KG, et al. Association of comorbid conditions and mortality in hemodialysis patients in Europe, Japan, and the United States: The Dialysis Outcomes and Practice Patterns Study (DOPPS). J Am Soc Nephrol 2003;14:3270-7.
30Held PJ, Port FK, Wolfe RA, et al. The dose of hemodialysis and patient mortality. Kidney Int 1996;50:550-6.
31Babitt JL, Lin HY. Mechanisms of anemia in CKD. J Am Soc Nephrol 2012;23:1631-4.
32Kou K, Hung SC, Tseng WC, et al. Association of anemia and iron parameters with mortality among patients undergoing prevalent hemodialysis in Taiwan: The AIM-HD study. J Am Heart Assoc 2018;7:e009206.
33Cecilia MG. The emerging role of phosphate in vascular calcification. Kidney Int 2009;75:890-7.
34Strozecki P, Adamowicz A, Nartowicz E, Odrowaz-Sypniewska G, Wlodarczyk Z, Manitius J. Parathormon, calcium, phosphorus, and left ventricular structure and function in normotensive hemodialysis patients. Ren Fail 2001;23:115-26.
35Eddington H, Hoefield R, Smeeta S, et al. Serum phosphate and mortality in patients with chronic kidney disease. Clin J Am Soc Nephrol 2010;5:2251-7.
36Kim T, Streja E, Soohoo M, et al. Serum ferritin variations and mortality in incident hemodialysis patients. Am J Nephrol 2017; 46:120-30.
37Park KS, Ryu GW, Jhee JH, et al. Serum ferritin predicts mortality regardless of inflammatory and nutritional status in patients starting dialysis: a prospective cohort study. Blood Purif 2015;40:209-17.
38De Mutsert R, Grootendorst DC, Indemans F, Boeschoten EW, Kridiet RT, Dekker FW, et al. Association between serum albumin and mortality in dialysis patients is partly explained by inflammation, and not by malnutrition. J Ren Nutr 2009;19:127-35.